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Cataract surgery has become one of the most frequently performed surgeries in the United States, and it is easily the most common surgery in eye care. Yet, it has also become a highly technical procedure with many nuances to consider. Ensuring patients have the best possible chance of achieving their refractive target and being happy with their vision requires diligence and precision—and this is especially true for patients paying out of pocket for a premium implant.
While every clinic’s particular process for the perioperative management of cataract patients will differ, there are nevertheless several important principles that are likely applicable for the wide swath of patients. In the following pages, I highlight five areas of focus for management of the surgical cataract patient that I believe to be important for both providing a successful outcome and making sure patients have a positive experience.
OPTIMIZE THE OCULAR SURFACE …
At our clinic, we place a high priority on evaluating and optimizing the ocular surface prior to surgery. This has several benefits, including giving the patient the best chance to achieve the desired refractive outcome and ensuring the accuracy of measurements. In addition, because corneal nerves are truncated during the procedure, cataract surgery will induce a certain amount of dryness in the early postoperative period. Unresolved ocular surface disease will exacerbate any existing issue, whereas treating it beforehand will help facilitate healing, improve comfort for the patient, and decrease the longevity of irritation postoperatively.
Our protocol for ocular surface evaluation begins with a SPEED questionnaire, with the answers alerting us to potential visual symptoms that will help direct the examination and subsequent testing. Our goal is to identify any issues and resolve them without having to delay the actual procedure. However, for patients getting a premium or toric lens, the threshold to delay surgery is much lower. These kinds of implants—and the patients paying out of pocket for them—have a much lower tolerance for any refractive error. Ideally, we would prefer to observe stability of the ocular surface over the course of at least two consecutive appointments before proceeding. This thinking changes for patients with corneal dystrophy or more severe corneal problems such as Sjögren syndrome, as these issues, in my experience, greatly compromise the likelihood of a successful outcome with a premium IOL.
… BUT DO NOT FORGET THE REST OF THE EYE
In addition to ocular surface issues, we are also diligent about ruling out macular or retinal pathology that might dissuade our surgeons from implanting a premium IOL. Macular issues, such as macular degeneration, drusen, scaring, or holes, may indicate a need for specialist referral, and they are also relative contraindications for a premium IOL.
PROPERLY EDUCATE PATIENTS TO HELP MANAGE EXPECTATIONS THROUGHOUT THE PROCESS
Ensuring patients are matched with the lens that will allow them the vision they want postoperatively begins with rigorous testing and evaluation during the initial surgical examination, but that cannot be the sum total of our efforts. Patients typically have three separate encounters in which they learn about the various options available to them: a counselor who knows the surgeon’s particular preferences; the interaction with the surgeon and optometric staff; and, finally, the surgery scheduler who will reiterate the information and make sure the patient understands all the information.
Those multiple touch points are entirely intentional, as they somewhat follow a mantra in public speaking: tell them what you are going to tell them; tell them; then tell them what you told them. There is a great deal of information that must be conveyed to patients during the preoperative period. However, for many patients, the prospect of surgery induces anxiety and fear that may make it hard to retain that information. Clinical protocols and processes aside, this is one aspect of working with patients when empathy and understanding are the best asset.
One reason why education is so important is that it helps to establish proper expectations for the final outcome. The adage to underpropose and overdeliver really rings true: If you set patients up with unreasonable expectations about what the surgery or the technology used can do, you are really setting that patient up for failure—especially with regard to premium lenses. There is no question that modern lens options are designed to give patients a better chance of achieving the vision they want postoperatively. However, while advances in technology have improved predictability, nothing is without room for error.
To anyone involved in the regular care of cataract patients, the subject of managing expectations preoperatively is not new. Yet, the message is worth repeating, especially in the context of providing a good experience. To that end, I find it curious that our field does not place the same emphasis on managing expectations during the postoperative period, especially when the vision is not where it should be. The healing process can be variable, and when patients do not see the results immediately or as quickly as they expected, they may start to doubt their decisions. Therefore, sometimes it may be necessary to do a little hand holding and counseling to reinforce their understanding and confidence. This is particularly true when the patient is between surgeries, with one eye completed and the other yet to have surgery. At this point in the process, especially with premium lenses, the end goal can become hard for the patient to visualize, so to speak.
BE SENSITIVE TO COST CONCERNS BUT NOT AT THE EXPENSE OF THE FINAL OUTCOME
The topical therapies used prior to and after cataract surgery are fairly standard—most patients get an antibiotic to reduce the risk of infection, a nonsteroidal antiinflammatory drug, and a steroid, which act synergistically to reduce inflammation, including cystoid macular edema. Which agents are used and for how long remains a subject of debate. What is less questionable, at least in the eyes of our surgeons, is whether branded or generic formulations are most desirable.
Many patients in our clinic express concern about the cost of their medications. This is reasonable and understandable. Yet, depending on insurance and rebates offered, generics are not necessarily cheaper, and they may not always be the best option for the patient. Because branded medications are put through rigorous clinical trials, their safety and efficacy are known variables. With generic products, we are dealing with an unknown quantity that is not subject to the same kind of testing. In cataract surgery, where we are making every effort to improve the accuracy and predictability of outcomes, it does not seem to make sense to use products, when possible, that carry uncertain risks. My colleagues and I have observed a greater incidence of corneal irritation and dryness among patients who use generic products during the perioperative cataract period, especially among those with pre-existing dry eye.
Some newer alternatives exist to the traditional triad of operative ocular medications, such as compounded drops and dropless surgery. Benefits of compounded drops often include a lower cost and increased compliance due to fewer drops needed. Dropless surgery, while not used currently by our surgeons, has increased in popularity in recent years. Medication is injected into the eye at the time of the surgery allowing the patient to be free from the need of postoperative drops. In both cases, there is a lower risk for corneal irritation and dryness, either by reduction of number of drops or elimination of drops completely.
Cost concerns are very legitimate, and we need to be sensitive to them—we never want patients to have to choose between paying the rent and getting their eye drops. At the same time, branded medications provide patients the best chance of achieving the goal they started out with, and that is to regain visual ability that has been compromised by changes in the crystalline lens.
LEARN THE SURGEONS’ PREFERENCES
There are six surgeons in our practice who perform cataract surgery and I work with all of them. Each surgeon does things a little differently. For example, one surgeon uses subconjunctival steroid injection at the time of surgery in cases where there is a pre-existing risk of increased postoperative inflammation, such as patients with a history of rheumatoid arthritis.
Keeping everyone’s personal preferences straight can get confusing, especially in a high-volume practice. However, understanding those nuances can be critically important to maintaining an efficient operation. In our case, we are fortunate that the surgeons have collaborated on designing a protocol for the perioperative management of cataract patients that standardizes the treatment of most patients that come through the clinic. Thus, the variations from the norm are minimized.
That said, understanding the preferences of the various surgeons in one’s practice, as well as appreciating how they like to operate, will assure that everyone is on the same page. This, in turn, helps to minimize confusion and maintains a high level of efficiency. It may seem like a minor consideration in the grand scheme, but when all members of the eye care team have a clear understanding of the perioperative protocol, it serves to keep the patient’s best interest as the focus of attention.
Entire textbooks can and have been written about the evidence-based care of cataract patients. There are many nuances and testing requirements to consider, and each is as important as the next. Fundamentally, however, the role of the optometrist in the integrated, or comanaged, setting is to assure that the patient is properly prepared for surgery and that he or she is afforded the greatest chance of obtaining the desired visual outcome. Achieving that goal depends significantly on how well the perioperative care plan is executed. An equally important aspect is the ability to listen to and respond quickly and empathetically to the needs of the patient. There can never be an absolute guarantee; yet, when the best interest of the patient is the central focus, the potential for a successful outcome is greatly enhanced.
Cecelia Koetting, OD, FAAO
• referral optometric care and externship program coordinator, Virginia Eye Consultants, Norfolk
• (757) 622-2200; http://www.virginiaeyeconsultants.com; firstname.lastname@example.org
• financial interest: none acknowledged